Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Template LTC Pandemic Plan MHCA updated 082406
Document related concepts
Health equity wikipedia , lookup
Patient safety wikipedia , lookup
Swine influenza wikipedia , lookup
Influenza A virus subtype H5N1 wikipedia , lookup
Human mortality from H5N1 wikipedia , lookup
Viral phylodynamics wikipedia , lookup
Avian influenza wikipedia , lookup
Transmission (medicine) wikipedia , lookup
Transmission and infection of H5N1 wikipedia , lookup
Transcript
Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Pandemic Influenza Plan _____________________________________ (Facility Name) Page 1 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ TABLE OF CONTENTS Introduction……………………………………………………………… 3-4 Organizational Planning and Decision Making Committee………… 5 State Government/ Health Department Contacts…………………… 6 Hospital Contacts………………………………………………………… 6 Health Alert Network (HAN) Contacts……………………………….. 7 Emergency Management Agency (EMA) Contacts………………… 7 Surveillance and Monitoring …………………………………………. 8 Infection Control Procedures…………………………………………. 9 Resident Care Protocols……………………………………………… 10 Vaccine and Antiviral Plan…………………………………………… 11 Management of Acutely Ill Residents………………………………. 12 Resident Death Procedures………………………………………… 13 Communications Plan………………………………………………. 14 -16 Education and Training Plan………………………………………. 17 Human Resources Issues…………………………………………. 18 -19 Critical Staffing Levels…………………………………………….. 20 Supply Disruption…………………………………………………… 21- 22 Appendixes Maine CDC Case Detection0……… ……………………Appendix A HHS/CDC Pandemic Influenza Pandemic Infection Control Recommendations…………………………………Appendix B Key Supplier Contacts and Procedures…………………..Appendix C Staff Telephone List…………………………………………Appendix D Page 2 of 44 23 -26 27 -42 43 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Introduction ________________________ considers planning critical to ensure an (Facility Name) appropriate and sustainable healthcare response to an influenza pandemic. It is essential for long-term care facilities to assess and plan for pandemic influenza response based on the unique needs and circumstances of each facility and it’s community. Long-term care facilities are accustomed to responding to yearly seasonal influenza outbreaks and have protocols in place to manage these. An influenza pandemic has greater potential to cause rapid increases in illness and death than virtually any other natural health threat. A pandemic, or global epidemic, occurs when there is a major change in the influenza virus so that most or all of the world’s population has never been exposed previously and is thus vulnerable to the virus. Pandemic flu presents an entirely new set of challenges for long-term care facilities that must be addressed with an entirely separate frame of reference. The Differences Between Seasonal and Pandemic Influenza Seasonal Flu Pandemic Flu Occurs every year Occurs infrequently, only 3 times in past century Occurs at any time of the year Occurs during the winter; U.S. flu season begins in December and ends in March Most people recover within 1-2 weeks without medical treatment Very young, very old and chronically ill are at highest risk of serious illness Some people will not recover, even with medical treatment People of every age may be at risk of serious illness Page 3 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Pandemic Influenza Initiation of Stages by Phases and Levels Emergency Level 1 Level 2 Level 3 Level 4 Level 5 Management Day to Active Health Full-Scale Recovery Response Day Surveillance Response Activation Operations World Health Organization (WHO) Phases 1-6 InterPandemic Period Pandemic Pandemic Pandemic Post Alert Period Alert Period Pandemic Period Period Phase 1-3 Phase 4-5 Phase 5 Phase 6 Long-term care facilities, as providers of health care, typically do not function in the public health area. We are not first responders or primary care providers, but we do interact with and depend on most community health care services. Because of the unique role of long-term care facilities in the community, reaction to a pandemic influenza will be primarily to protect our residents and staff. This Pandemic influenza plan is designed to go into effect at Level 3/WHO Phase 5 or above. This plan shall be incorporated into emergency management (all hazards) planning and exercises for the facility. Throughout this planning process, every effort has been made to ensure the facility's plan complements other community and regional planning efforts. Page 4 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Organization Planning and Decision Making ______________________ has created a multidisciplinary planning committee to (Facility Name) specifically address pandemic influenza preparedness planning. Members of the facility planning committee include those positions checked below: Check Below Position Individuals Name Administrator / who also serves as Committee Chairperson, Incident Commander and Public Information Officer Director of Nursing Medical Director Infection Control Director Staff Development Coordinator Maintenance Director Food Service Supervisor Social Services Director Therapy Director Activities Director Pharmacy Consultant Transportation Aide Licensed Nurse Licensed Nurse Certified Nursing Assistant Certified Nursing Assistant Clergy/Chaplain Resident Family Member Page 5 of 44 Home Phone Cellular Phone Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ State Government / Health Department Contacts The facility pandemic planning committee has identified the following local health department and Maine CDC contacts to assist in providing information on pandemic influenza planning resources. Agency Name Contact Phone(s) Maine CDC Representative Regional Resource Center Contact Local Health Department (if applicable) Hospital Contacts The facility pandemic planning committee has identified the following area hospital’s points of contacts. Hospital Name Contact Person Name Contact Person Title Page 6 of 44 Contact Phone(s) Include after hour contact information Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Health Alert Network (HAN) Contacts The Health Alert Network is a national and Maine CDC system for interactive communication around significant public health events. Hospital, county and state-level pandemic influenza planners are registered HAN users. Through HAN the Maine CDC will provide appropriate guidelines and updates through the Health Alert Network (HAN) to include updated clinical guidelines, policies and other critical public health material. Long-term care providers may register with the HAN network through the Regional Resource Center to receive critical information directly from the HAN source in a timely fashion. HAN Coordinator Name Facility / Position Contact Phone(s) Include after hour contact information Emergency Management Agency Contacts The facility pandemic planning committee has identified the following state, county and local emergency management agency (EMA) contacts for assistance in planning and during an actual pandemic disaster situation. Emergency Management Agency Contact Person Name Contact Person Title Page 7 of 44 Contact Phone(s) Include after hour contact information Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Surveillance and Monitoring Within this facility, monitoring of seasonal influenza-like illness in residents occurs as part of the normal infection control and quality improvement process. Influenza-like illness outbreaks, as a category 2 'Notifiable Condition' to the State of Maine under State law, is reported to the Maine CDC Division of Infectious Diseases at 1-800-821-5821. An outbreak in a long-term care facility is defined as 1 or more laboratory-confirmed residents with influenza or 3 or more residents with influenza-like illness [fever of > 100º F AND cough and/or sore throat in the absence of a known cause] identified on same floor or unit during a short (e.g., 48-72 hour) period. Residents suspected of novel influenza virus, such as avian influenza A (H5N1), based on clinical symptoms and recent travel (see Appendix A), should be reported immediately at 1-800-821-5821. A facility staff person has been assigned responsibility for surveillance and detection of the presence of pandemic influenza in residents, monitoring public health advisories (federal and state), and updating the pandemic response coordinator and members of the pandemic influenza planning committee when pandemic influenza has been reported. A back up staff person has been designated. The names of the responsible individuals are: Name Title Primary Secondary Page 8 of 44 Contact Phone Numbers Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Infection Control Procedures Appendix B HHS/CDC Pandemic Influenza Pandemic Infection Control Recommendations Discussion Points: o Your facility should adopt pandemic influenza infection control procedures consistent with those from CDC (see Appendix A) o Consider developing a Pandemic infection control policy that requires direct care staff to use Standard (www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html) and Droplet Precautions (i.e., mask for close contact) (www.cdc.gov/ncidod/dhqp/gl_isolation_droplet.html) with symptomatic residents. o Develop a plan for implementing Respiratory Hygiene/Cough Etiquette throughout the facility. (See www.cdc.gov/flu/professionals/infectioncontrol/ resphygiene.htm.) o Social Distancing Plan Page 9 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Resident Care Procedures See Appendix A HHS/CDC Pandemic Influenza Pandemic Infection Control Recommendations Discussion Points: o Your facility should adopt pandemic influenza resident care procedures consistent with those from CDC o Symptomatic residents will be cohorted using one or more of the following strategies:2 1) confining symptomatic residents and their exposed roommates to their room, 2) placing symptomatic residents together in one area of the facility, or 3) closing units where symptomatic and asymptomatic residents reside (i.e., restricting all residents to an affected unit, regardless of symptoms). o Social Distancing Plan o Do you have a policy stating staff who are assigned to work on affected units will not work on other units. o State of Maine Minimum Direct Care Staffing requirements by regulation are: 1:5 Days 1:10 Evenings 1:15 Nights How would you staff your facility with critically low numbers of employees?? See Section on Critical Staffing page 19 The facility pandemic planning committee will discuss and consider the necessity of changes in the standard of care, closure of units, closure of the entire facility to new admissions, and limitation of outside visitation when pandemic influenza has been identified in the facility or the community. A the time of the pandemic threat, specific risks and facts will be identified and reviewed in conjunction with all available information at the time. The facility Administrator as the committee chairperson shall approve and convey information regarding such decision. Page 10 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Vaccine and Antiviral Plan Discussion Points: A vaccine and antiviral use plan should be developed in conjunction with national Pandemic Planning priorities, your medical director and your local community and state public health planning. o The CDC website below contains current recommendations and guidance for the use, availability, access, and distribution of vaccines and antiviral medications during a pandemic: www.hhs.gov/pandemicflu/plan/sup6.html and www.hhs.gov/pandemicflu/plan/sup7.html. o Discuss availability and access to as part of your plan. How will you obtain influenza vaccine or antiviral prophylaxis for residents? o Discuss Pneumovax and seasonal influenza vaccine efforts as well as pandemic influenza o Include vaccination of health care workers as a national priority in this section Page 11 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Management of Acutely Ill Residents In the event of a pandemic, it is likely that hospital beds will become unavailable. Acutely ill facility residents may have to be managed in place at the facility. In this event, this facility will consult the primary care physician and the facility medical director and adjust the residents care plan appropriately. Discussion Points: o Will your local hospital(s) provide any special services (telephone, computer based, other) to help you manage acutely ill residents in the facility as an alternative to hospitalization? o Discussion point for your facility planning committee – Do you want to sign agreements with area hospitals to facilitate the admission of non-influenza patients to the long-term care facility to facilitate utilization of community acute care resources for more seriously ill patients. o Facility space has been identified that could be adapted for use as expanded inpatient beds and information provided to local and regional planning contacts. Page 12 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Resident Death Procedures Your facility committee should consider: o Include funeral directors and emergency management agency personnel in discussions around resident deaths (County level EMA have local “mass casualty plan” in place that you need to be aware of) o Discussion of your present death certification process. Efforts on a state level are underway to make the death certificate process an electronic one. Include your funeral directors in this conversation. o A contingency plan has been developed for managing an increased need for post mortem care and disposition of deceased residents. o In the event of large scale resident deaths, who would be contacted at EMA to obtain refrigerator trucks, body bags, and other required items o Should you change/update your current protocols for post mortem care Page 13 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Facility Communications Plan Pandemic influenza communication strategies are a critical and necessary component of pandemic influenza preparedness. The facility incident commander has the responsibility for official communications with public health authorities during a pandemic and for communications with staff, residents, and their families regarding the status and impact of pandemic influenza in the facility. This role has been assigned to the facility administrator, who also serves as the facility public information officer (PIO). This facility’s PIO is cognizant of the fact that in a public health emergency the Director of the Maine CDC will provide official information to the public. This facility recognizes that having one voice that speaks for the facility during a pandemic will help ensure the delivery of timely and accurate information. Every effort will be made by this facility to coordinate public communication with state, county and local officials. Identify your facilities communication plan here - how signs, phone trees, and other methods of communication will be used to inform staff, family members, visitors, and other persons coming into the facility (e.g., sales and delivery people) about the status of pandemic influenza in the facility, in the event of a pandemic influenza outbreak. Information on pandemic influenza and relevant instructions (e.g., suspension of visitation, where to obtain information) will been developed by the pandemic planning committee in the event of a pandemic influenza outbreak for residents, their families, visitors and staff. The information will be transferred to posters which will be placed at each entrance to the building and on the facility pandemic influenza website. Page 14 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Pandemic Communication Plan Checklist Implement National Incident Management System (NIMS) communication based protocols (Activation of Public Information Officer and Joint Information Center) Notify employees of the State’s declaration of the current pandemic level Post door signs notifying visitors of Pandemic Influenza risks and/or “lockdown” as per direction of Pandemic Influenza Committee Pandemic Influenza Committee meets regularly to discuss communications Deployment of information telephone hotline, notification of local radio/television stations and website information regarding staff instructions and visitation instructions Designate staff for telephone duty Deployment of information on facility website Daily briefings with message: empathy, current situation and numbers, what is not known, what we are doing to address unknowns, what people should do: - To residents - To all staff - Facility signage posted - Telephone hotline - Website Other:_______________________________________________________ Page 15 of 44 Maine Health Care Association Pandemic Plan Template for LTC Facilities Draft #2 8/24/06 ______________________________________________________________ Communication issues to consider during a pandemic Adapted from Centers for Disease Control and Prevention Goals of communication with regard to pandemic influenza: Orient public behavior to benefit the community (avoid panic). Reduce confusion. Control use of scarce hospital resources (human, supplies, and financial). Answer questions and concerns. Key issues in communicating Give people things to do. Don’t say, “Don’t worry,”—give facts and let people decide for themselves. Uncertainty causes panic. Contradictory messages create uncertainty; information is empowering. Don’t make promises we can’t keep, be truthful. No jargon. Avoid humor. Refute allegations—don’t repeat them. Discuss what you know, not what you think. Be regretful, not defensive. Acknowledge fears. What the public wants to know What happened? What was found that may affect me? What can I do to protect myself /my family? Who/What caused this? Can you fix it? Who is in charge? Has this been contained? Are victims being helped? What can I expect, right now and later? What should we do? Did you have any forewarning? Page 16 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Education and Training Related to Pandemic Influenza The following facility staff person has been designated with primary responsibility for coordinating education and training on pandemic influenza, to include identification of and access to available programs and the maintenance of records of personnel attendance. Name Title Contact Phone Numbers Ongoing education and training efforts seek to ensure that all personnel are aware that the facility has a pandemic emergency plan, how to locate the plan, receive a summary of the plan and are aware of the implications of, basic prevention and infection control measures necessary to prevent the spread of pandemic influenza. Discussion points: o Your facility will need to identify the specific issues your staff need to be aware of and train them on this information. o Is this now part of new hire orientation along with the rest of the disaster plan? Will you give all staff a copy of the plan? o How will you train existing staff on this topic? o How will you not alarm them? o The most basic information they will need is around communications in the event of a pandemic – Identify how you will train them on this topic. o As part of the education and training efforts consider the need for residents and family members of residents education to be provided by the facility on the facilities planning efforts. o Is a facility representative(s) involved in the discussion of local plans for inter-facility communication during a pandemic – this should be discussed in this section Page 17 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Pandemic Influenza Related Human Resource Issues Governmental recommendations around private sector planning recommend the assumption that up to 25%-60% of the facility staff may be absent for a period of about 3 weeks at the height of a pandemic wave, with lower levels of staff absent for a few weeks one either side of the peak. These absences may be due to employees who: o Care for the ill o Are under voluntary or imposed home quarantine due to an ill household member o Care for children dismissed from school o Feel safer at home o Are ill or incapacitated by the virus This facility recognizes that effective continuity planning includes protection of personnel during an influenza pandemic. Points for facility discussion: o Develop an occupational health plan for addressing staff absences and other related occupational issues that includes the following: o Assessing employees who arrive at work in the event of a pandemic o Expediting delivery of influenza vaccine or antiviral prophylaxis to residents and staff as recommended by the state health department. o A system to monitor influenza vaccination of personnel. o A plan for managing personnel who are at increased risk for influenza complications (e.g., pregnant women, immunocompromised workers) by placing them on administrative leave or altering their work location (e.g. work at/from home) o Development of a liberal/non-punitive sick leave policy that addresses the needs of symptomatic personnel and facility staffing needs. The policy considers: (see Maine Law Handout on Personnel Leave During Public Health Crisis) o The handling of personnel who develop symptoms while at work. Page 18 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ o When personnel may return to work after having pandemic influenza. o What to do if personnel who are symptomatic come to work – occupational health checks before and after shifts o Personnel who need to care for family members who become ill o A plan to educate staff to self-assess and report symptoms of pandemic influenza before reporting for duty. o Consider cross training of staff for various duties and how/when this should occur – (Please note: This a good exercise for Nursing Home Culture Change Efforts as well!) o Consider use of volunteers, family members and other community resources are direct and indirect care givers (assuming relaxation of regulations have been ordered by the Governor). Who internally would train these unskilled workers? o Can residents temporarily be sent home to be cared for by family members? o Institution of work related travel restrictions during period of pandemic o Review of your insurance policy coverage with your carriers related to employees: o Health Insurance o Disability Insurance o Liability Insurance o Workers Compensation o Life Insurance o Attach a copy and/ or refer your facilities leave policy Page 19 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Critical Staffing Levels The following facility staff person has been designated with primary responsibility for conducting a daily assessment of staffing status and needs during an influenza pandemic. A back-up designee has been appointed. Name Title Contact Phone Numbers Primary Secondary Discussion points: o How would a surge of patients from the hospital be addressed in terms of staffing? o What are the absolutely minimal necessary tasks that must be performed for basic resident care? o Think through changes in standard of care / regulatory relaxation that might need to be implemented in the case of a severe pandemic for basic survival o Create a contingency staffing plan that considers the minimum staffing needs and prioritizes critical and non-essential services based on residents' health status, functional limitations, disabilities, and essential facility operations. o Legal counsel, Maine CDC, and Maine Department of Health and Human Services Licensing and Certification Division should be consulted to determine the applicability of declaring a facility "staffing crisis" and appropriate emergency staffing alternatives, consistent with state law. o Does your facility staffing plan includes strategies for collaborating with local and regional planning and response groups to address widespread healthcare staffing shortages during a crisis. o Does your facility need a plan for expediting the credentialing and training of non-facility staff brought in from other locations to provide patient care when the facility reaches a staffing crisis. o How could you use volunteers most effectively? Page 20 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Supply Chain Disruptions Maine’s long term care facilities are required by regulation to have a dietary disaster plan in place. This facility maintains a ____day inventory of food that would be used in the event of a pandemic disaster and disruptions to the food supply. The dietary disaster plan has been reviewed in conjunction by the pandemic influenza planning committee and a copy of the dietary plan can be found_____________ (or is attached). A list of the essential facility suppliers and their work / off hour contact numbers can be in Appendix C. These suppliers have been included in this facilities planning process. Any special procedures for distribution and delivery during a pandemic can be found in Appendix C. The pandemic influenza planning committee has reviewed essential supplies and materials needed by this facility and has made estimates the quantities of selected essential materials and equipment that would be needed during a sixweek pandemic. Inventories have been increased for these supplies effective________________. Consumable and Durable Supply Needs Item Antimicrobial soap Alcohol-based gel Disposable N95, surgical and procedure masks Face shields (disposable or reusable) Gowns Gloves Facial tissues Batteries Disposable Briefs Oxygen Tanks Bed Linen Laundry Detergent Housekeeping Cleaning Chemicals 6 Week Supply Need Page 21 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Housekeeping Equipment ADD TO THIS LIST Discuss plans to address likely supply shortages, including strategies for using normal and alternative channels for procuring needed resources. Page 22 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Appendices List Appendix A Maine CDC Pandemic Influenza Case detection and clinical management of suspect or confirmed human cases of novel influenza virus (WHO Phases 3 & 4) Appendix B HHS/CDC Pandemic Influenza Pandemic Infection Control Recommendations Appendix C List of key facility suppliers, their contact numbers and special procedures for distribution and delivery during a pandemic Appendix D Facility Staff Phone List Page 23 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Appendix A Maine CDC Pandemic Influenza Case detection and clinical management of suspect or confirmed human cases of novel influenza virus (WHO Phases 3 & 4) Situation: No human cases of novel influenza are present in the community. Human cases might be present in another country or another region of the United States. CLINICAL CRITERIA A patient who has an illness that: Requires hospitalization or is fatal; AND Has or had a documented temperature of >38’C (>100.4’F); AND Has radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established If no to any1, treat as clinically indicated, but reevaluate if suspicious AND EPIDEMIOLOGIC CRITERIA At least one of the following potential exposures within 10 days of symptom onset: History of travel to a country with influenza H5N1 documented in poultry, wild birds, and/or humans2 AND at least one of the following potential exposures during travel: o Direct contact with (e.g., touching) sick or dead domestic poultry; o Direct contact with surfaces contaminated with poultry feces; o Consumption of raw or incompletely cooked poultry or poultry products; o Direct contact with sick or dead wild birds suspected or confirmed to have influenza H5N1; o Close contact (approach within 1 meter [approx. 3 feet]) of a person who was hospitalized or died due to a severe unexplained respiratory illness; Close contact (approach within 1 meter [approx. 3 feet]) of an ill patient who was confirmed or suspected to have H5N1; Worked with live influenza H5N1 virus in a laboratory. If no to both criteria, treat as clinically indicated, but reevaluate if suspicion If yes to either criterion Initiate Standard and Droplet Precautions3 Treat as clinically indicated4 Notify Maine CDC at 1-800-821-5821 to report suspect human novel influenza; Maine CDC will review clinical and epidemiologic criteria with reporting clinician. Initiate general work-up as clinically indicated5 Collect and send specimens for novel influenza testing after consulting with Maine CDC Division of Infectious Disease and Health and Environmental Testing Laboratory6 Begin empiric antiviral treatment7 Help identify contacts, including HCWs8 All influenza testing negative11 Novel influenza positive by culture or RT-PCR Continue Standard and Droplet Precautions3 Continue antivirals7 Do not cohort with seasonal influenza patients Treat complications, such as secondary bacterial pneumonia, as indicated10 Provide clinical updates to Maine CDC (1-800821-5821) Continue infection control precautions, as clinically appropriate3 Treat complications, such as secondary bacterial pneumonia, as indicated10 Consider discontinuing antivirals, if considered appropriate7 Seasonal influenza positive by culture or RT-PCR Continue Standard and Droplet Precautions3 Page 24 of 44 Continue antivirals for a minimum of 5 days7 Treat complications, such as secondary Maine CDC July 13, 2006 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Footnotes (HHS Pandemic Influenza Plan and Supplements are available at www.hhs.gov/pandemicflu/plan/) 1. 2. 3. 4. 5. 6. Testing for avian influenza (H5N1) virus infection can be considered on a case-by-case basis in consultation with Maine CDC (1-800-821-5821) for: A patient (hospitalized or ambulatory) with mild or atypical disease (for example a patient with respiratory illness and fever who does not require hospitalization, or a patient with significant neurologic or gastrointestinal symptoms in the absence of respiratory disease) who has one of the exposures listed as epidemiologic criteria; OR A patient with severe or fatal respiratory disease whose epidemiological information is uncertain, unavailable, or otherwise suspicious but does not meet the epidemiological criteria (examples include a returned traveler from an influenza H5N1-affected country whose exposures are unclear or suspicious, a person who had contact with sick or well-appearing poultry, etc.) Further evaluation and diagnostic testing should also be considered for outpatients with strong epidemiologic risk factors and mild or moderate illness: Consult with Maine CDC at 1-800-8215821. Updated information on areas where novel influenza virus transmission is suspected or documented is available at the CDC website at www.cdc.gov/flu/avian/outbreaks/current.htm; the OIE website at www.oie.int/eng/en_index.htm; and the WHO website at www.who.int/csr/disease/avian_influenza/en/ Standard and Droplet Precautions should be used when caring for patients with novel influenza or seasonal influenza. Information on infection precautions that should be implemented for all respiratory illnesses is provided at: www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm Hospitalization should be based on all clinical factors, including the potential for infectiousness and the ability to practice adequate infection control. If hospitalization is not clinically warranted, and treatment and infection control is feasible in the home, the patient may be managed as an outpatient: Consult with Maine CDC. The patient and his or her household should be provided with information on infection control procedures to follow at home. The patient and close contacts should be monitored for illness by Maine CDC staff. The general work-up should be guided by clinical indications. Depending on the clinical presentation and the patient’s underlying health status, initial diagnostic testing might include: Pulse oximetry; Chest radiograph; Complete blood count (CBC) with differential; Blood cultures; Sputum (in adults), tracheal aspirate, pleural effusion aspirate (if pleural effusion is present) Gram stain and culture; Antibiotic susceptibility testing (encouraged for all bacterial isolates); Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs for common viral respiratory pathogens, such as influenza A and B, adenovirus, parainfluenza viruses, and respiratory syncytial virus, particularly in children; In adults with radiographic evidence of pneumonia, Legionella and pneumococcal urinary antigen testing; If clinicians have access to rapid and reliable testing (e.g., PCR) for M. pneumoniae and C. pneumoniae, adults and children <5 yrs with radiographic pneumonia should be tested; Comprehensive serum chemistry panel, if metabolic derangement or other end-organ involvement, such as liver or renal failure, is suspected. Guidelines for novel influenza virus testing can be found in HHS Plan Supplement 2. Oropharyngeal swab specimens and lower respiratory specimens (e.g. bronchoalveolar lavage or tracheal aspirate [for intubated patients]) should be collected for novel influenza virus testing. These specimens are preferred because they appear to contain the highest quantity of virus for influenza H5N1 detection, as determined on the basis of available data. Nasal or nasopharyngeal swab specimens are acceptable, but may contain less virus and therefore not be optimal specimens for virus detection. Detection of influenza H5N1 is more likely from specimens collected within the first 3 days of illness onset. If possible serial specimens should be obtained over several days from the same patient. Bronchoalveolar lavage is considered to be a high-risk aerosol-generative procedure. Infection control precautions should include the use of gloves, gown, goggles or face shield, and a fittested respirator with an N-95 or higher rated filter. A loose fitting powered air-purifying respirator (PAPR) may be used if fit-testing is not possible (for example, if the person has a beard). Detailed guidance on infection control precautions for health care workers care for suspected influenza H5N1 patients is available at www.cdc.gov/flu/avian/professional/infectcontrol.htm Swabs used for specimen collection should have a Dacron tip and an aluminum or plastic shaft. Swabs with calcium alginate or cotton tip and wooden shafts are not recommended. Specimens should be placed at 4’C immediately after collection. Page 25 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Laboratory personnel should contact Maine CDC (1-800-821-5821) Epidemiology and HETL for advice on specimen preparation and transportation. 7. Strategies for the use of antiviral drugs are provided in HHS Plan Supplement 7. 8. Guidelines for the management of contacts in a healthcare setting are provided in HHS Plan Supplement 3. 9. Given the unknown sensitivity of tests for novel influenza viruses, interpretation of negative results should be tailored to the individual patient in consultation with the local health department. Novel influenza directed management may need to be continued, depending on the strength of clinical and epidemiologic suspicion. Antiviral therapy and isolation precautions for novel influenza may be discontinued on the basis of an alternative diagnosis. The following criteria may be considered for this evaluation: Absence of strong epidemiologic link to known cases of novel influenza; Alternative diagnosis confirmed using a test with a high positive-predictive value; Clinical manifestations explained by the alternative diagnosis Guidance on the evaluation and treatment of suspected post-influenza community-associated pneumonia is provided in HHS Plan Appendix 3. Page 26 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Appendix B: Influenza Pandemic Infection Control Recommendations HHS Pandemic Influenza Plan Supplement 4 Infection Control S4-III. Overview Supplement 4 provides guidance to healthcare and public health partners on basic principles of infection control for limiting the spread of pandemic influenza. These principles (summarized in Box 1) are common to the prevention of other infectious agents spread by respiratory droplets. Supplement 4 also includes guidance on the selection and use of personal protective equipment (PPE); hand hygiene and safe work practices; cleaning and disinfection of environmental surfaces; handling of laboratory specimens; and post-mortem care. The guidance also covers infection control practices related to the management of infectious patients, the protection of persons at high-risk for severe influenza or its complications, and issues concerning occupational health. Supplement 4 also provides guidance on how to adapt infection control practices in specific healthcare settings, including hospitals, nursing homes and other long-term care facilities, pre-hospital care (emergency medical services [EMS]), medical offices and other ambulatory care settings, and during the provision of professional home healthcare services. The section on hospital care covers detection of entering patients who may be infected with pandemic influenza; implementation of source-control measures to limit virus dissemination from respiratory secretions; hospitalization of pandemic influenza patients; and detection and control of nosocomial transmission. In addition, Supplement 4 includes guidance on infection control procedures for pandemic influenza patients in the home or in alternative care sites that may be established if local hospital capacity is overwhelmed by a pandemic. Finally, it includes recommendations on infection control in schools, workplaces, and community settings. Supplement 4 does not address the use of vaccines and antivirals in the control of influenza transmission in healthcare settings and the community. These issues are addressed in Supplements 6 and 7, respectively. S4-I. Rationale The primary strategies for preventing pandemic influenza are the same as those for seasonal influenza: vaccination, early detection and treatment with antiviral medications (as discussed elsewhere in this plan), and the use of infection control measures to prevent transmission during patient care. However, when a pandemic begins, a vaccine may not yet be widely available, and the supply of antiviral drugs may be limited. The ability to limit transmission in healthcare settings will, therefore, rely heavily on the appropriate and thorough application of infection control measures. While it is commonly accepted that influenza transmission requires close contact—via exposure to large droplets (droplet Page 27 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ transmission), direct contact (contact transmission), or near-range exposure to aerosols (airborne transmission)—the relative clinical importance of each of these modes of transmission is not known. The infection control guidance provided in this supplement is based on our knowledge of routes of influenza transmission (S4-II.A), the pathogenesis of influenza (S4-II.B), and the effects of influenza control measures used during past pandemics and interpandemic periods (S4-II.C) (see also supporting references in the Appendix). Given some uncertainty about the characteristics of a new pandemic strain, all aspects of preparedness planning for pandemic influenza must allow for flexibility and real-time decision-making that take new information into account as the situation unfolds. The specific characteristics of a new pandemic virus—virulence, transmissibility, initial geographic distribution, clinical manifestation, risk to different age groups and subpopulations, and drug susceptibility—will remain unknown until the pandemic gets underway. If the new virus is unusual in any of these respects, HHS and its partners will provide updated infection control guidance. S4-II. Influenza Transmission Modes of transmission Despite the prevalence of influenza year after year, most information on the modes of influenza transmission from person to person is indirect and largely obtained through observations during outbreaks in healthcare facilities and other settings (e.g., cruise ships, airplanes, schools, and colleges); the amount of direct scientific information is very limited. However, the epidemiologic pattern observed is generally consistent with spread through close contact (i.e., exposure to large respiratory droplets, direct contact, or near-range exposure to aerosols). While some observational and animal studies support airborne transmission through small particle aerosols, there is little evidence of airborne transmission over long distances or prolonged periods of time (as is seen with M. tuberculosis). The relative contributions and clinical importance of the different modes of influenza transmission are currently unknown. Droplet transmission (www.cdc.gov/ncidod/hip/ISOLAT/std_prec_excerpt.htm) Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during the performance of certain procedures such as suctioning and bronchoscopy. Transmission via large-particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only short distances (about 3 feet) through the air. Because Page 28 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission. Based on epidemiologic patterns of disease transmission, large droplet transmission has been considered a major route of influenza transmission. However, data directly demonstrating large droplet transmission of influenza in human outbreaks is indirect and limited. Contact transmission (www.cdc.gov/ncidod/hip/ISOLAT/contact_prec_excerpt.htm) Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patientcare activities that require physical contact. Direct-contact transmission also can occur between two patients (e.g., by hand contact), with one serving as the source of infectious microorganisms and the other as a susceptible host. Indirectcontact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment. Contact transmission of influenza may occur through either direct skin-to-skin contact or through indirect contact with virus in the environment. Transmission via contaminated hands and fomites has been suggested as a contributing factor in some studies. However, there is insufficient data to determine the proportion of influenza transmission that is attributable to direct or indirect contact. Airborne transmission (www.cdc.gov/ncidod/hip/ISOLAT/airborne_prec_excerpt.htm) Airborne transmission occurs by dissemination of either airborne droplet nuclei or small particles in the respirable size range containing the infectious agent. Microorganisms carried in this manner—such as M. tuberculosis— may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face-to-face contact with (or been in the same room with) the infectious individual. Organisms transmitted in this manner must be capable of sustaining infectivity, despite desiccation and environmental variation that generally limit survival in the airborne state. Preventing the spread of agents that are transmitted by the airborne route requires the use of special air handling and ventilation systems (e.g., negative pressure rooms). The relative contribution of airborne transmission to influenza outbreaks is uncertain. Evidence is limited and is principally derived from laboratory studies in animals and some observational studies of influenza outbreaks in humans, particularly on cruise ships and airplanes, where other mechanisms of transmission were also present. Additional information suggesting airborne transmission was reported in a Veterans Administration Hospital study that found lower rates of influenza in wards exposed to ultraviolet radiation (which inactivates influenza viruses) than in wards without UV radiation. Another study indicated that humidity can play a role in the infectivity of aerosolized influenza, although the influence of humidity on the formation of droplet nuclei was not evaluated. Page 29 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Small-particle aerosols. There is no evidence that influenza transmission can occur across long distances (e.g., through ventilation systems) or through prolonged residence in air, as seen with airborne diseases such as tuberculosis. However, transmission may occur at shorter distances through inhalation of small-particle aerosols (droplet nuclei), particularly in shared air spaces with poor air circulation. An experimental study involving human volunteers found that illness could be induced with substantially lower virus titers when influenza virus was administered as a small droplet aerosol rather than as nasal droplets, suggesting that infection is most efficiently induced when virus is deposited in the lower rather than the upper respiratory tract. While this study supports the possibility of droplet nuclei transmission of influenza, the proportion of infections acquired through droplet nuclei—as compared with large droplet or contact spread—is unknown. It is likely that some aerosol-generating procedures (e.g., endotracheal intubation, suctioning, nebulizer treatment, bronchosocopy) could increase the potential for dissemination of droplet nuclei in the immediate vicinity of the patient. (Although transmission of SARS-CoV was reported in a Canadian hospital during an aerosol-generating procedure [intubation], it occurred in a situation involving environmental contamination with respiratory secretions.) Although this mode of transmission has not been evaluated for influenza, additional precautions for healthcare personnel who perform aerosol-generating procedures on influenza patients may be warranted. Pathogenesis of influenza and implications for infection control The cellular pathogenesis of human influenza indicates that infection principally takes place within the respiratory tract. While conjunctivitis is a common manifestation of systemic influenza infection, the ocular route of inoculation and infection has not been demonstrated for human influenza viruses. This may not be true with certain avian species of influenza (e.g., H7N7) that have been associated primarily with conjunctivitis in humans. This information suggests that preventing direct and indirect inoculation of the respiratory tract is of utmost importance for preventing person-to-person transmission when caring for infectious patients. Control of transmission in healthcare facilities Outbreaks of influenza have been prevented or controlled through a set of well established strategies that include vaccination of patients and healthcare personnel; early detection of influenza cases in a facility; use of antivirals to treat ill persons and, if recommended, as prophylaxis; isolation of infectious patients in private rooms or cohort units; use of appropriate barrier precautions during patient care, as recommended for Standard and Droplet Precautions (Box 1); and administrative measures, such as restricting visitors, educating patients and staff, and cohorting healthcare workers assigned to an outbreak unit. Page 30 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ These are the primary infection control measures recommended in this plan. They will be updated, as necessary, based on the observed characteristics of the pandemic influenza virus. Page 31 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ S4-IV. Recommendations for Infection Control in Healthcare Settings The recommendations for infection control described below are generally applicable throughout the different pandemic phases. In some cases, as indicated, recommendations may be modified as the situation progresses from limited cases to widespread community illness. Basic infection control principles for preventing the spread of pandemic influenza in healthcare settings The following infection control principles apply in any setting where persons with pandemic influenza might seek and receive healthcare services (e.g. hospitals, emergency departments, out-patient facilities, residential care facilities, homes). Details of how these principles may be applied in each healthcare setting follow. o o o o o o o o o o o o Limit contact between infected and non-infected persons2 Isolate infected persons (i.e., confine patients to a defined area as appropriate for the healthcare setting). Limit contact between nonessential personnel and other persons (e.g., social visitors) and patients who are ill with pandemic influenza. Promote spatial separation in common areas (i.e., sit or stand as far away as possible— at least 3 feet—from potentially infectious persons) to limit contact between symptomatic and non-symptomatic persons. Protect persons caring for influenza patients in healthcare settings from contact with the pandemic influenza virus. Persons who must be in contact should: Wear a surgical or procedure mask3 for close contact with infectious patients. Use contact and airborne precautions, including the use of N95 respirators, when appropriate [S4-IV.C]. Wear gloves (gown if necessary) for contact with respiratory secretions. Perform hand hygiene after contact with infectious patients. Contain infectious respiratory secretions: Instruct persons who have “flu-like” symptoms (see below) to use respiratory hygiene/cough etiquette (See Box 2). Promote use of masks4 by symptomatic persons in common areas (e.g., waiting rooms in physician offices or emergency departments) or when being transported (e.g., in emergency vehicles). Symptoms of influenza include fever, headache, myalgia, prostration, coryza, sore throat, and cough. Otitis media, nausea, and vomiting are also commonly reported among children. Typical influenza (or “flu-like”) symptoms, such as fever, may not always be present in elderly patients, young children, patients in long-term care facilities, or persons with underlying chronic illnesses (see Supplement 5, Box 2). Management of infectious patients Respiratory hygiene/cough etiquette Respiratory hygiene/cough etiquette has been promoted as a strategy to contain respiratory viruses at the source and to limit their spread in areas where infectious patients might be awaiting medical care (e.g., physician offices, emergency departments) (see S4-IV.B.2). Page 32 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ The impact of covering sneezes and coughs and/or placing a mask on a coughing patient on the containment of respiratory secretions or on the transmission of respiratory infections has not been systematically studied. In theory, however, any measure that limits the dispersal of respiratory droplets should reduce the opportunity for transmission. Masking may be difficult in some settings, e.g., pediatrics, in which case the emphasis will be on cough hygiene. The elements of respiratory hygiene/cough etiquette include: o o o o o Education of healthcare facility staff, patients, and visitors on the importance of containing respiratory secretions to help prevent the transmission of influenza and other respiratory viruses Posted signs in languages appropriate to the populations served with instructions to patients and accompanying family members or friends to immediately report symptoms of a respiratory infection as directed Source control measures (e.g., covering the mouth/nose with a tissue when coughing and disposing of used tissues; using masks on the coughing person when they can be tolerated and are appropriate) Hand hygiene after contact with respiratory secretions, and Spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. Droplet precautions and patient placement Patients with known or suspected pandemic influenza should be placed on droplet precautions for a minimum of 5 days from the onset of symptoms. Because immunocompromised patients may shed virus for longer periods, they may be placed on droplet precautions for the duration of their illness. Healthcare personnel should wear appropriate PPE (see S4-IV.C). The placement of patients will vary depending on the healthcare setting (see setting-specific guidance). If the pandemic virus is associated with diarrhea, contact precautions (i.e., gowns and gloves for all patient contact) should be added. CDC will update these recommendations if changes occur in the anticipated pattern of transmission. Infection control practices for healthcare personnel Infection control practices for pandemic influenza are the same as for other human influenza viruses and primarily involve the application of standard and droplet precautions (Box 1) during patient care in healthcare settings (e.g., hospitals, nursing homes, outpatient offices, emergency transport vehicles). This guidance also applies to healthcare personnel going into the homes of patients. During a pandemic, conditions that could affect infection control may include shortages of antiviral drugs, decreased efficacy of the vaccine, increased virulence of the influenza strain, shortages of single-patient rooms, and shortages of personal protective equipment. These issues may necessitate changes in the standard recommended infection control practices for influenza. CDC will provide updated infection control guidance as circumstances dictate. Additional guidance is provided for family members providing home care (S4- Page 33 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ IV.G) and for use in public settings (e.g., schools, workplace) where people with pandemic influenza may be encountered (S4-V and S4-VI). Personal protective equipment (PPE) PPE for standard and droplet precautions PPE is used to prevent direct contact with the pandemic influenza virus. PPE that may be used to provide care includes surgical or procedure masks, as recommended for droplet precautions, and gloves and gowns, as recommended for standard precautions (Box 1). Additional precautions may be indicated during the performance of aerosol-generating procedures (see below). Information on the selection and use of PPE is provided at www.cdc.gov/ncidod/hip/isolat/isolat.htm/. Masks (surgical or procedure) o o o o Wear a mask when entering a patient’s room. A mask should be worn once and then discarded. If pandemic influenza patients are cohorted in a common area or in several rooms on a nursing unit, and multiple patients must be visited over a short time, it may be practical to wear one mask for the duration of the activity; however, other PPE (e.g., gloves, gown) must be removed between patients and hand hygiene performed. Change masks when they become moist. Do not leave masks dangling around the neck. Upon touching or discarding a used mask, perform hand hygiene. Gloves o o o o o o A single pair of patient care gloves should be worn for contact with blood and body fluids, including during hand contact with respiratory secretions (e.g., providing oral care, handling soiled tissues). Gloves made of latex, vinyl, nitrile, or other synthetic materials are appropriate for this purpose; if possible, latex-free gloves should be available for healthcare workers who have latex allergy. Gloves should fit comfortably on the wearer’s hands. Remove and dispose of gloves after use on a patient; do not wash gloves for subsequent reuse. Perform hand hygiene after glove removal. If gloves are in short supply (i.e., the demand during a pandemic could exceed the supply), priorities for glove use might need to be established. In this circumstance, reserve gloves for situations where there is a likelihood of extensive patient or environmental contact with blood or body fluids, including during suctioning. Use other barriers (e.g., disposable paper towels, paper napkins) when there is only limited contact with a patient’s respiratory secretions (e.g., to handle used tissues). Hand hygiene should be strongly reinforced in this situation. Gowns o o o o o Wear an isolation gown, if soiling of personal clothes or uniform with a patient’s blood or body fluids, including respiratory secretions, is anticipated. Most patient interactions do not necessitate the use of gowns. However, procedures such as intubation and activities that involve holding the patient close (e.g., in pediatric settings) are examples of when a gown may be needed when caring for pandemic influenza patients. A disposable gown made of synthetic fiber or a washable cloth gown may be used. Ensure that gowns are of the appropriate size to fully cover the area to be protected. Gowns should be worn only once and then placed in a waste or laundry receptacle, as appropriate, and hand hygiene performed. If gowns are in short supply (i.e., the demand during a pandemic could exceed the supply) priorities for their use may need to be established. In this circumstance, reinforcing the situations in which they are needed can reduce the volume used. Page 34 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Alternatively, other coverings (e.g., patient gowns) could be used. It is doubtful that disposable aprons would provide the desired protection in the circumstances where gowns are needed to prevent contact with influenza virus, and therefore should be avoided. There are no data upon which to base a recommendation for reusing an isolation gown on the same patient. To avoid possible contamination, it is prudent to limit this practice. Goggles or face shield In general, wearing goggles or a face shield for routine contact with patients with pandemic influenza is not necessary. If sprays or splatter of infectious material is likely, goggles or a face shield should be worn as recommended for standard precautions. Additional information related to the use of eye protection for infection control can be found at http://www.cdc.gov/niosh/topics/eye/eyeinfectious.html. PPE for special circumstances PPE for aerosol-generating procedures During procedures that may generate increased small-particle aerosols of respiratory secretions (e.g., endotracheal intubation, nebulizer treatment, bronchoscopy, suctioning), healthcare personnel should wear gloves, gown, face/eye protection, and a N95 respirator or other appropriate particulate respirator. Respirators should be used within the context of a respiratory protection program that includes fit-testing, medical clearance, and training. If possible, and when practical, use of an airborne isolation room may be considered when conducting aerosol-generating procedures. PPE for managing pandemic influenza with increased transmissibility The addition of airborne precautions, including respiratory protection (an N95 filtering face piece respirator or other appropriate particulate respirator), may be considered for strains of influenza exhibiting increased transmissibility, during initial stages of an outbreak of an emerging or novel strain of influenza, and as determined by other factors such as vaccination/immune status of personnel and availability of antivirals. As the epidemiologic characteristics of the pandemic virus are more clearly defined, CDC will provide updated infection control guidance, as needed. Precautions for early stages of a pandemic Early in a pandemic, it may not be clear that a patient with severe respiratory illness has pandemic influenza. Therefore precautions consistent with all possible etiologies, including a newly emerging infectious agent, should be implemented. This may involve the combined use of airborne and contact precautions, in addition to standard precautions, until a diagnosis is established. Caring for patients with pandemic influenza Healthcare personnel should be particularly vigilant to avoid: Page 35 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ o o Touching their eyes, nose or mouth with contaminated hands (gloved or ungloved). Careful placement of PPE before patient contact will help avoid the need to make PPE adjustments and risk self-contamination during use. Careful removal of PPE is also important. (See also: http://www.cdc.gov/ncidod/hip/ppe/default.htm.) Contaminating environmental surfaces that are not directly related to patient care (e.g., door knobs, light switches) Hand hygiene Hand hygiene has frequently been cited as the single most important practice to reduce the transmission of infectious agents in healthcare settings (see http://www.cdc.gov/handhygiene/pressrelease.htm) and is an essential element of standard precautions. The term “hand hygiene” includes both handwashing with either plain or antimicrobial soap and water and use of alcohol-based products (gels, rinses, foams) containing an emollient that do not require the use of water. o o o o If hands are visibly soiled or contaminated with respiratory secretions, wash hands with soap (either non-antimicrobial or antimicrobial) and water. In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience. Always perform hand hygiene between patient contacts and after removing PPE. Ensure that resources to facilitate handwashing (i.e., sinks with warm and cold running water, plain or antimicrobial soap, disposable paper towels) and hand disinfection (i.e., alcohol-based products) are readily accessible in areas in which patient care is provided. For additional guidance on hand hygiene see http://www.cdc.gov/handhygiene/. Disposal of solid waste Standard precautions are recommended for disposal of solid waste (medical and non-medical) that might be contaminated with a pandemic influenza virus: o o o Contain and dispose of contaminated medical waste in accordance with facility-specific procedures and/or local or state regulations for handling and disposal of medical waste, including used needles and other sharps, and non-medical waste. Discard as routine waste used patient-care supplies that are not likely to be contaminated (e.g., paper wrappers). Wear disposable gloves when handling waste. Perform hand hygiene after removal of gloves. Linen and laundry Standard precautions are recommended for linen and laundry that might be contaminated with respiratory secretions from patients with pandemic influenza: o o o o o Place soiled linen directly into a laundry bag in the patient’s room. Contain linen in a manner that prevents the linen bag from opening or bursting during transport and while in the soiled linen holding area. Wear gloves and gown when directly handling soiled linen and laundry (e.g., bedding, towels, personal clothing) as per standard precautions. Do not shake or otherwise handle soiled linen and laundry in a manner that might create an opportunity for disease transmission or contamination of the environment. Wear gloves for transporting bagged linen and laundry. Perform hand hygiene after removing gloves that have been in contact with soiled linen and laundry. Wash and dry linen according to routine standards and procedures (www.cdc.gov/ncidod/hip/enviro/guide.htm). Page 36 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Dishes and eating utensils Standard precautions are recommended for handling dishes and eating utensils used by a patient with known or possible pandemic influenza: o o o Wash reusable dishes and utensils in a dishwasher with recommended water temperature (www.cdc.gov/ncidod/hip/enviro/guide.htm). Disposable dishes and utensils (e.g., used in an alternative care site set-up for large numbers of patients) should be discarded with other general waste. Wear gloves when handling patient trays, dishes, and utensils. Patient-care equipment Follow standard practices for handling and reprocessing used patient-care equipment, including medical devices: o o o Wear gloves when handling and transporting used patient-care equipment. Wipe heavily soiled equipment with an EPA-approved hospital disinfectant before removing it from the patient’s room. Follow current recommendations for cleaning and disinfection or sterilization of reusable patient-care equipment. Wipe external surfaces of portable equipment for performing x-rays and other procedures in the patient’s room with an EPA-approved hospital disinfectant upon removal from the patient’s room. Environmental cleaning and disinfection Cleaning and disinfection of environmental surfaces are important components of routine infection control in healthcare facilities. Environmental cleaning and disinfection for pandemic influenza follow the same general principles used in healthcare settings. Cleaning and disinfection of patient-occupied rooms (See: www.cdc.gov/ncidod/hip/enviro/Enviro_guide_03.pdf) o Wear gloves in accordance with facility policies for environmental cleaning and wear a surgical or procedure mask in accordance with droplet precautions. Gowns are not necessary for routine cleaning of an influenza patient’s room. o Keep areas around the patient free of unnecessary supplies and equipment to facilitate daily cleaning. o Use any EPA-registered hospital detergent-disinfectant. Follow manufacturer’s recommendations for use-dilution (i.e., concentration), contact time, and care in handling. o Follow facility procedures for regular cleaning of patient-occupied rooms. Give special attention to frequently touched surfaces (e.g., bedrails, bedside and over-bed tables, TV controls, call buttons, telephones, lavatory surfaces including safety/pull-up bars, doorknobs, commodes, ventilator surfaces) in addition to floors and other horizontal surfaces. o Clean and disinfect spills of blood and body fluids in accordance with current recommendations for Isolation Precautions (www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm). Cleaning and disinfection after patient discharge or transfer o o o Follow standard facility procedures for post-discharge cleaning of an isolation room. Clean and disinfect all surfaces that were in contact with the patient or might have become contaminated during patient care. No special treatment is necessary for window curtains, ceilings, and walls unless there is evidence of visible soiling. Do not spray (i.e., fog) occupied or unoccupied rooms with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit. Page 37 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Postmortem care Follow standard facility practices for care of the deceased. Practices should include standard precautions for contact with blood and body fluids. Laboratory specimens and practices Follow standard facility and laboratory practices for the collection, handling, and processing of laboratory specimens. Occupational health issues Healthcare personnel are at risk for pandemic influenza through community and healthcare-related exposures. Once pandemic influenza has reached a community, healthcare facilities must implement systems to monitor for illness in the facility workforce and manage those who are symptomatic or ill. o o o o Implement a system to educate personnel about occupational health issues related to pandemic influenza. Screen all personnel for influenza-like symptoms before they come on duty. Symptomatic personnel should be sent home until they are physically ready to return to duty. Healthcare personnel who have recovered from pandemic influenza should develop protective antibody against future infection with the same virus, and therefore should be prioritized for the care of patients with active pandemic influenza and its complications. These workers would also be well suited to care for patients who are at risk for serious complications from influenza (e.g., transplant patients and neonates). Personnel who are at high risk for complications of pandemic influenza (e.g., pregnant women, immunocompromised persons) should be informed about their medical risk and offered an alternate work assignment, away from influenza-patient care, or considered for administrative leave until pandemic influenza has abated in the community. Reducing exposure of persons at high risk for complications of influenza Persons who are well, but at high risk for influenza or its complications (e.g., persons with underlying diseases), should be instructed to avoid unnecessary contact with healthcare facilities caring for pandemic influenza patients (i.e., do not visit patients, postpone nonessential medical care). Healthcare setting-specific guidance All healthcare facilities should follow the infection control guidance in S4-IV.A-E above. The following guidance is intended to address setting-specific infection control issues that should also be considered. Page 38 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Nursing homes and other residential facilities Residents of nursing homes and other residential facilities will be at particular risk for transmission of pandemic influenza and disease complications. Pandemic influenza can be introduced through facility personnel and visitors; once a pandemic influenza virus enters such facilities, controlling its spread is problematic. Therefore, as soon as pandemic influenza has been detected in the region, nursing homes and other residential facilities should implement aggressive measures to prevent introduction of the virus. Prevention or delay of pandemic influenza virus entry into the facility o o Control of visitors o Post visual alerts (in appropriate languages) at the entrance to the facility restricting entry by persons who have been exposed to or have symptoms of pandemic influenza. o Enforce visitor restrictions by assigning personnel to verbally and visually screen visitors for respiratory symptoms at points of entry to the facility. o Provide a telephone number where persons can call for information on measures used to prevent the introduction of pandemic influenza. Control of personnel o Implement a system to screen all personnel for influenza-like symptoms before they come on duty. Symptomatic personnel should be sent home until they are physically able to return to duty. Monitoring patients for pandemic influenza and instituting appropriate control measures Despite aggressive efforts to prevent the introduction of pandemic influenza virus, persons in the early stages of pandemic influenza could introduce it to the facility. Residents returning from a hospital stay, outpatient visit, or family visit could also introduce the virus. Early detection of the presence of pandemic influenza in a facility is critical for ensuring timely implementation of infection control measures. o o o o Early in the progress of a pandemic in the region, increase resident surveillance for influenza-like symptoms. Notify state or local health department officials if a case(s) is suspected. If symptoms of pandemic influenza are apparent (see Supplement 5), implement droplet precautions for the resident and roommates, pending confirmation of pandemic influenza virus infection. Patients and roommates should not be separated or moved out of their rooms unless medically necessary. Once a patient has been diagnosed with pandemic influenza, roommates should be treated as exposed cohorts. Cohort residents and staff on units with known or suspected cases of pandemic influenza. Limit movement within the facility (e.g., temporarily close the dining room and serve meals on nursing units, cancel social and recreational activities). Page 39 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Box 1. Summary of Infection Control Recommendations for Care of Patients with Pandemic Influenza Component Recommendations Standard Precautions See www.cdc.gov/ncidod/hip/ISOLAT/std_prec_excerpt.htm Hand hygiene Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items; after removing gloves; and between patient contacts. Hand hygiene includes both handwashing with either plain or antimicrobial soap and water or use of alcohol-based products (gels, rinses, foams) that contain an emollient and do not require the use of water. If hands are visibly soiled or contaminated with respiratory secretions, they should be washed with soap (either non-antimicrobial or antimicrobial) and water. In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience. Personal protective equipment (PPE) Gloves Gown Face/eye protection (e.g., surgical or procedure mask and goggles or a face shield) For touching blood, body fluids, secretions, excretions, and contaminated items; for touching mucous membranes and nonintact skin During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated During procedures and patient care activities likely to generate splash or spray of blood, body fluids, secretions, excretions Safe work practices Avoid touching eyes, nose, mouth, or exposed skin with contaminated hands (gloved or ungloved); avoid touching surfaces with contaminated gloves and other PPE that are not directly related to patient care (e.g., door knobs, keys, light switches). Patient resuscitation Avoid unnecessary mouth-to-mouth contact; use mouthpiece, resuscitation bag, or other ventilation devices to prevent contact with mouth and oral secretions. Soiled patient care equipment Handle in a manner that prevents transfer of microorganisms to oneself, others, and environmental surfaces; wear gloves if visibly contaminated; perform hand hygiene after handling equipment. Soiled linen and laundry Handle in a manner that prevents transfer of microorganisms to oneself, others, and to environmental surfaces; wear gloves (gown if necessary) when handling and transporting soiled linen and laundry; and perform hand hygiene. Needles and other sharps Use devices with safety features when available; do not recap, bend, break or hand-manipulate used needles; if Page 40 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ recapping is necessary, use a one-handed scoop technique; place used sharps in a puncture-resistant container. Environmental cleaning and disinfection Use EPA-registered hospital detergent-disinfectant; follow standard facility procedures for cleaning and disinfection of environmental surfaces; emphasize cleaning/disinfection of frequently touched surfaces (e.g., bed rails, phones, lavatory surfaces). Disposal of solid waste Contain and dispose of solid waste (medical and non-medical) in accordance with facility procedures and/or local or state regulations; wear gloves when handling waste; wear gloves when handling waste containers; perform hand hygiene. Respiratory hygiene/cough etiquette Source control measures for persons with symptoms of a respiratory infection; implement at first point of encounter (e.g., triage/reception areas) within a healthcare setting. Cover the mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacles; perform hand hygiene after contact with respiratory secretions; wear a mask (procedure or surgical) if tolerated; sit or stand as far away as possible (more than 3 feet) from persons who are not ill. Droplet Precautions www.cdc.gov/ncidod/hip/ISOLAT/droplet_prec_excerpt.htm Patient placement Place patients with influenza in a private room or cohort with other patients with influenza.* Keep door closed or slightly ajar; maintain room assignments of patients in nursing homes and other residential settings; and apply droplet precautions to all persons in the room. *During the early stages of a pandemic, infection with influenza should be laboratory-confirmed, if possible. Personal protective equipment Wear a surgical or procedure mask for entry into patient room; wear other PPE as recommended for standard precautions. Patient transport Limit patient movement outside of room to medically necessary purposes; have patient wear a procedure or surgical mask when outside the room. Other Follow standard precautions and facility procedures for handling linen and laundry and dishes and eating utensils, and for cleaning/disinfection of environmental surfaces and patient care equipment, disposal of solid waste, and postmortem care. Aerosol-Generating Procedures During procedures that may generate small particles of respiratory secretions (e.g., endotracheal intubation, bronchoscopy, nebulizer treatment, suctioning), healthcare personnel should wear gloves, gown, face/eye protection, and a fit-tested N95 respirator or other appropriate particulate respirator. Page 41 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Respiratory Hygiene/Cough Etiquette To contain respiratory secretions, all persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should be instructed to: o o o o Cover the nose/mouth when coughing or sneezing. Use tissues to contain respiratory secretions. Dispose of tissues in the nearest waste receptacle after use. Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials. Healthcare facilities should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette in waiting areas for patients and visitors: o o o Provide tissues and no-touch receptacles for used tissue disposal. Provide conveniently located dispensers of alcohol-based hand rub. Provide soap and disposable towels for handwashing where sinks are available. Masking and separation of persons with symptoms of respiratory infection During periods of increased respiratory infection in the community, persons who are coughing should be offered either a procedure mask (i.e., with ear loops) or a surgical mask (i.e., with ties) to contain respiratory secretions. Coughing persons should be encouraged to sit as far away as possible (at least 3 feet) from others in common waiting areas. Some facilities may wish to institute this recommendation year-round. Updated by CDC December 2005 Page 42 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Appendix C: List of key facility suppliers, their contact numbers and special procedures for distribution and delivery during a pandemic Page 43 of 44 Maine Health Care Association Pandemic Planning Template Draft #1 8/11/06 _______________________________________________________________ Appendix D Facility Staff Phone List Page 44 of 44
